CMS Bars Funds for Certain Preventable Conditions

The Centers for Medicare & Medicaid Services on June 6 published a final rule that will deny federal matching funds under Medicaid for state payments to providers for certain preventable health care-acquired illnesses or injuries. The rule implements a provision of the Patient Protection and Affordable Care Act (PPACA) that requires the secretary of Health and Human Services to make Medicaid payment adjustments for health care-acquired conditions (HCACs).

The following is a list of the Medicare

HACs:

1. Foreign Object Retained After

    Surgery

2. Air Embolism

3. Blood Incompatibility

4. Stage III and IV Pressure Ulcers

5. Falls and Trauma

6. Fractures

   a. Dislocations.

   b. Intracranial Injuries

   c. Crushing Injuries

   d. Burns

   e. Electric Shock

7. Manifestations of Poor Glycemic

    Control

    a. Diabetic Ketoacidosis

    b. Nonketotic Hyperosmolar Coma

    c. Hypoglycemic Coma

    d. Secondary Diabetes with

        Ketoacidosis

    e. Secondary Diabetes with

        Hyperosmolarity

8. Catheter-Associated Urinary Tract

    Infection (UTI)

    a. Vascular Catheter-Associated

        Infection

9. Surgical Site Infection Following:

    a. Coronary Artery Bypass Graft

        (CABG)—Mediastinitis

    b. Bariatric Surgery

        i. Laparoscopic Gastric Bypass

        ii.Gastroenterostomy

        iii. Laparoscopic Gastric Restrictive

             Surgery

    c. Orthopedic Procedures

         i. Spine

         ii. Neck

         iii. Shoulder

         iv. Elbow

10. Deep Vein Thrombosis (DVT)/

      Pulmonary Embolism (PE)

      a. Total Knee Replacement (excluding obstetric and pediatric)

      b. Hip Replacement (excluding obstetric and pediatric)

The rule further requires that provider contracts contain provisions requiring providers to identify and report these conditions. The rule’s effective date is July 1, 2011, however CMS has stated that it intends to delay compliance action on these provisions until July 1, 2012. In a proposed version of the rule issued in February, CMS originally set a July 1, 2011, effective date for the new Medicaid payment prohibitions. In an introduction to the final rule, however, CMS acknowledged, “States may need additional time to work with providers to implement sound policies and reporting mechanisms.”